Summary Shortly after midnight on 26 February 2004, while transiting Queen Charlotte Sound, British Columbia, the commercial fishing vessel HopeBay listed suddenly to starboard and capsized. The four persons on board abandoned the vessel by jumping into the sea. Search and rescue personnel initially rescued one person and recovered the bodies of two others. The body of the fourth person was recovered later the same day. The vessel remained afloat for about 12hours before sinking. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Vessel Description The HopeBay was a small fishing vessel of closed construction, having an all-welded steel double-chine hull with a partly raised forecastle deck, a stern ramp and a skeg. The hull below the main deck was subdivided by five transverse watertight bulkheads, separating (from forward): the forepeak; engine room; two forward (No.1 port and starboard) and two after (No.2 port and starboard) insulated fish holds divided by a centre line cofferdam; a third hold (No.3 hold) designated as a void space; and the lazarette, which housed the steering gear. Four diesel oil tanks were arranged on the port and starboard sides outboard of the lazarette. Fresh water storage tanks were located on the port and starboard sides of the engine room (see Figure1). A deckhouse located forward of amidships enclosed the wheelhouse, crew accommodation, and engine room access. A weathertight dutch door giving access to the working deck was fitted on the starboard side of the aft transverse bulkhead of the deckhouse. Doors on the port and starboard sides of the aft bulkhead of the wheelhouse provided access down to the working deck. The vessel was rigged for stern trawling operations and was equipped with two net drums installed on the working deck. The working deck was covered with a wooden grating. To facilitate loading of fish, two pound boards,3 91cm (3ft) high, were located longitudinally on top of the grating. Aft of the accommodation, access to the below-deck compartments was provided by hatch covers, and additionally by manholes fitted either in the hatch cover or the working deck (See Figure1.) Fish-loading deck scuttles were also fitted into the deck plating outboard of the hatchways in way of the No.2 fish holds and No.3 hold. Freeing ports were located in the bulwarks. History of the Voyage On 17 February 2004, the trawler HopeBay was refuelled in Port Hardy, B.C. Five days later, on February22, 16tons of ice were loaded into the fish holds and, at around midnight, the vessel departed for fishing grounds in Queen Charlotte Sound. Fuel and fresh water tanks were nearly full, and there were four persons on board: the skipper, the mate, the engineer, and one fishery observer contracted by the Department of Fisheries and Oceans. The vessel arrived at the fishing grounds at about 16004 on 23February2004 and began fishing at approximately1830. Fishing continued for some 25 hours until around 1930on February24 , when Nos.1 and 2fish holds were nearly full with a combination of fish, salt water, and ice. No.3 hold remained empty. By the time the fish were stowed, the weather had deteriorated and the HopeBay sought refuge from impending southeasterly gales. The vessel had a starboard list as it steamed westward for two hours to Heater Harbour on Kunghit Island, Queen Charlotte Islands, B.C., where it anchored at about 2130. (See Figure2.) On the following morning, 25 February 2004, with conditions forecast to improve late that afternoon, the HopeBay departed the anchorage at approximately 1145and began a southeasterly voyage towards a fish-processing plant in Port Hardy. Both paravanes were deployed, and the top half of the dutch door between the galley and the exterior working deck was latched ajar, allowing fresh air to circulate through the vessel. Soon after leaving Heater Harbour, sea water was being shipped onto the working deck through the freeing ports in the vessel's bulwarks and occasionally over the stern. The HopeBay was considered a "wet boat" as it was common for sea water to cover the entire surface of the HopeBay's main working deck to a depth in excess of 8cm whenever the vessel was making way while heavily laden. During the afternoon and evening, the vessel proceeded on a southeasterly course. Shortly after 2300, the skipper initiated a very high frequency (VHF) radio telephone call with another fishing vessel during which he expressed concern about the slow rolling motion of the HopeBay and was considering making a northerly alteration of course toward Hakai Pass. Instead, he decided to continue on the established course toward Port Hardy. He then passed the wheelhouse watch to the mate and retired to his cabin. The fishery observer and the engineer were resting in their bunks in the forward part of the vessel. When the vessel was about two miles southwest of Goose Bank, southeast seas became more turbulent. The vessel pitched and rolled violently before heeling sharply to starboard. The skipper returned to the wheelhouse and assumed the conduct of the vessel. He reduced speed and, with the HopeBay heeling to starboard, placed the helm hard to port in an attempt to bring the vessel upright. When those manoeuvres failed, he ordered the two crew members and the fishery observer to don immersion suits and prepare to abandon the HopeBay. Being preoccupied with the emergency, and with no time to don an immersion suit, the skipper wore a floater coat. At 0000 on 26 February2004, a distress call was broadcast on VHF Channel16, giving the vessel's position as 5123.22'N, 1298.71'W. The call was acknowledged by Marine Communications and Traffic Services (MCTS) in Prince Rupert,B.C. The skipper, the two crew members, and the fishery observer made their way from the wheelhouse to the port side of the exterior boat deck. The skipper ordered the fishery observer to activate and launch the vessel's emergency position indicating radio beacon (EPIRB), which was fitted in a bracket fixed to the wheelhouse bulkhead. While attempting to do so, the device slipped from the observer's hand and fell to the working deck below. It floated free of the vessel and began transmitting. At the same time, the mate and engineer lifted the inflatable liferaft from its metal cradle atop the wheelhouse. The liferaft fell to the boat deck where its painter became entangled in the vessel's rigging. The raft then rolled into the sea over the starboard bulwarks and inflated. By order of the skipper, attempts were made to free it by the mate and engineer, however, with the HopeBay heeling heavily to starboard, water began downflooding through the partially open dutch door until the vessel capsized, trapping the liferaft underwater. Without benefit of the liferaft, all persons abandoned the vessel by jumping into the sea. Events Following the Capsizing The fishery observer clung to a food freezer which floated free from the boat deck of the HopeBay. The skipper initially clung to the fishery observer, while the two crew members floated nearby. Meanwhile, at 0003 on 26February2004, Prince Rupert MCTS communicated the vessel's distress to Joint Rescue Coordination Centre (JRCC) Victoria. This set in motion search and rescue (SAR) operations. A total of two air and four marine resources were used. A SAR technician rescued the fishery observer from the water and recovered the bodies of two crew members. The body of the skipper was recovered later. At1416, JRCC closed the HopeBay rescue operation. Vessel Certification The vessel was issued a Ship Inspection Certificate (SIC29) for a commercial fishing vessel not exceeding 150 tons gross tonnage on 30December1999, but this had expired on 31December2003. Personnel Certification and Experience The skipper of the HopeBay held a Transport Canada (TC) Certificate of Competency as Master of a Home Trade vessel of under 350gross tons, issued on 23January1997. He had over 20years' experience in the commercial fishing industry, including some 10years in command of the HopeBay. Neither of the two crew members held certificates of competency, nor were they required to. Both crew members had worked as fishers for more than 10years. The fishery observer had sailed on the vessel on two previous occasions. Neither the crew members nor the fishery observer had received Marine Emergency Duties training nor was it required. Consequent to the changes in the Crewing Regulations, Marine Emergency Duties (MED) training for fishers is now mandatory and is being phased in with completion by April2008. Weather At 1410, 24 February 2004, the Pacific Weather Centre of Environment Canada issued a forecast for Queen Charlotte Sound, predicting southeasterly gales that night. At 1030, 25 February 2004, the Weather Centre predicted the southeasterly gale force winds to back NE and ease to 15to 25knots in the afternoon, easing again to NE10 to 20knots at night with seas of 3to 4m subsiding to 3m. The outlook was for winds backing to moderate to strongNW. The gale warning ended at 1600, 25February2004. Winds were predicted to be northeasterly 20to 30knots, easing to 5to 15knots overnight, with wave heights of 2to 3m. At 0030 on 26 February 2004, Environment Canada's West Sea Otter Group weather buoy located within 15miles of the vessel's last reported position recorded the wind coming from 140(T) at a mean wind speed of 16knots gusting to 21knots with a significant wave height5 of approximately 2m. Environment At approximately 2330, 25 February 2004, the vessel was in the vicinity of a relatively shallow portion of Queen Charlotte Sound known as Goose Bank. The depth over the area, which covers an area of approximately 800square miles, is typically 25to 30fathoms, with the surrounding depth at least 60fathoms. Fishers familiar with Queen Charlotte Sound are aware that waves near the perimeter of Goose Bank can become steep and erratic. Vessel Construction and Modification History The HopeBay, previously named the LeroyandBarry, was constructed in 1967as a seiner with one large fish hold. In May1977, this was subdivided into No.1 port and starboard, and No.2 port and starboard fish holds, and No.3 hold. In 1986 the vessel was modified from a seiner to a trawler. Vessel Stability As a small fishing vessel of closed construction built before July1977 and not employed in catching herring or capelin, the HopeBay was not required to have its stability data assessed or approved by TC under the Small Fishing Vessel Inspection Regulations (SFVIR). However, a stability report approved on 07May1982 stipulated that there be no more than five tons of water ballast in the after peak tank6 when the vessel is fully loaded. This limit ensures adequate freeboard when fully loaded. The TSB carried out a post-occurrence stability analysis to assess the transverse stability of the vessel prior to and at the time of capsizing. Taking into consideration modifications made to the vessel after May1982, current lightship characteristics were determined. At the time of the occurrence, the vessel had a near-full load of fish, salt water, and ice. Diesel oil tanks Nos.1 and2 (P and S) were at about 80%of their capacity. Diesel oil tanks No.2 (P and S) were likely exceeding their five-ton limit. The post-occurrence stability analysis was carried out using various down-flooding points, such as the hatches or the dutch door. This was done in a static environment- i.e., one with no wind or waves- for a full load trawling (FLT) condition. The results show the vessel would have met the stability criteria of STAB4, but that the hatches would have been awash and even immersed at a relatively small angle of heel (15for hatch No.1). For this condition, the freeboard of the deck at midships would be about 0.42m (1.38feet). The wind and wave effects at various angles of encounter and wave lengths were later considered in a more realistic environment- again, with the vessel in FLTcondition. Results show that the vessel's ability to right itself was reduced significantly, below the STAB4 criteria. Covers for Openings into Holds and Deck Scuttles Five hatch covers, six manhole covers, and four deck scuttle covers located aft of the accommodation provided access to below-deck compartments. Each cover was designed to be weathertight, and each was on a coaming 15cm above the deck plating except for No.1 fish hold hatch coamings, which were 30cm above the deck. The hatch covers were designed to close and seal tightly against a gasket and were secured in position by means of a bolting arrangement. The deck scuttles were 30.5cm in diameter, and the closing arrangement was similar to that of the manhole covers. Entry into, and exit from, the holds was via oval-shaped manholes in the weathertight hatch covers/ working deck (see Photo2). The TSB has carried out extensive testing to two manufacturers' designs of single cross-bar type manhole covers similar to those used on board the HopeBay. This has revealed several inherent safety deficiencies: the operator is unable to see the cross bar when it is tightened from the deck of the vessel. There is a lack of visual and reliable tactile feedback that the cover has been correctly closed. an aluminum cover tends to warp under the influence of excessive loads and does not provide an effective seal. the short lever arm of the tee handle used for tightening does not allow sufficient torque to be created. In conjunction with the tubular nature of the O-ring, this creates a condition where the cross bar loses its initial pre-tension and becomes free. a combination of too-short cross bar stops and the large clearance between the spindle head and cover allows the cross bar to slip past the stops, leaving the cover inadequately secured. the design of the cover and the cross bar does not allow uniform distribution of the tightening force along the oval cover's long axis. Under an applied load, the cross bar acts as a fulcrum, allowing the opposite end of the cover to lift off the O-ring. the left-hand thread and consequent clockwise-to-open rotational direction of the spindle is counterintuitive, leading to incorrect operation. the manufacturers of the manhole covers do not provide their customers with operating or maintenance instructions. an unsecured manhole cover is vulnerable to being lifted off by wave action, leaving a compartment open to downflooding. These deficiencies make the covers prone to water leakage.7 Lifesaving Equipment The HopeBay carried lifesaving equipment as required by regulations. This equipment included an eight-person inflatable liferaft, a four-person boat, two life rings, five universal size immersion suits, five lifejackets, and an EPIRB. Liferafts are commonly stowed on top of the accommodation and wheelhouses of fishing vessels. In this instance, the liferaft was atop the wheelhouse in the vicinity of the boom and rigging. When deployed, it became entangled in the rigging and was unusable when the vessel capsized on top of it. There was no time for the crew to attempt to launch the four-person boat, which was lashed to the boat deck. The Board has previously addressed shortcomings in liferaft stowage and accessibility.8 In response, TCissued Ship Safety Bulletin (SSB) 09/1993, highlighting the recommended practice for the stowage of throw-over type inflatable liferafts. One recommended practice was that liferafts should be stowed such that, when lifted from their cradles, they can be deployed over the side of the vessel. In addition, TCinitiated a study to consider methods of improving the stowage of life-saving equipment on board fishing vessels. One objective was the development of a low-maintenance, cost-effective, safe, and efficient system for the stowage and deployment of small liferafts. However, the study was never completed. In the proposed Fishing Vessel Safety Regulations, anticipated to be completed in2008, TCintends to pursue provisions that will require all liferafts to be stowed such that they will float free if a fishing vessel capsizes and sinks. Immersion Suits Worn by Personnel Two crew members and the fishery observer donned immersion suits supplied by their employers. Examples of the two types of suits worn can be seen in Photo3. The fishery observer, who wore a newer-model suit, (shown in the left-hand photograph) was recovered after three hours of cold water immersion. When rescued, the wearer's undergarments were wet to the waist but he was still warm. By comparison, cold water filled the suits of both crew members who succumbed to hypothermia. The immersion suits used by the two crew members were approximately 15years old. One crew member's suit was found to be partially unzipped in the area of the neck and face seal. The second crew member's suit had a pinhole on the right biceps area. The design of these suits required the cuffs to be tucked inwards to prevent water from entering at the wrists. It is not known whether the cuffs of the crew members' suits were tucked in, but it is known that the manufacturer's instructions accompanying each suit at the time of purchase did not include this information. Immersion Suit Standard The Canadian General Standards Board9 (CGSB) immersion suit standard was developed under the premise that the suit would be used for "rapid uncontrolled use".10 The standard is intended to increase survival capability by reducing thermal shock upon entry into cold water, delaying the onset of hypothermia during immersion in cold water, providing acceptable flotation, and minimizing the risk of drowning. The current standard employs height and weight criteria11 for suit sizing. Suits are available in three adult sizes (small, universal, jumbo) and one child size. They can also be custom fit (see Table1). However, the majority of suits are of the universal size. Table 1. CGSB Marine Abandonment Suit Sizes The provision of a specific level of thermal protection is the main criterion in the production of immersion suits. Manufacturers meet or exceed CGSB thermal protection requirements by maintaining a balance between the loss of heat associated with water ingress into the suit and minimizing heat loss through increased insulation. There is a maximum acceptable leakage specified in the standard. To assess thermal protection, tests are conducted using both humans and mannequins.12 Human subjects, selected from defined areas along the regression line for height and weight of the general population, are used to determine the amount and location of water ingress when jumping into water from a height of at least 3m and swimming on one's back in a pool with a water temperature of not less than 18C. A mannequin is next used to determine the suit's thermal insulation. The same amount of water as found in the jump test and three times that recorded in the swim test is introduced in the previously identified locations and the mannequin is immersed in turbulent water with a wave height of 40cm and 2C. General Practices Respecting Immersion Suits The CGSB standard requires that information at the point of sale be made available regarding the use of the suit system, and should include the following: a description of the suit system; its maintenance and cleaning instructions, and depiction of donning instructions on the exterior of the storage container. However, the investigation revealed that: the buyer seldom takes the time to look at instructions prior to purchasing a suit; the seller does not always make the buyer aware of the features/limitations of the suit; immersion suits are not tried for size either at the time of purchase or later for maintenance purposes, and practice drills to don the suit are rarely carried out. Instead, suits are usually purchased and then stowed until an emergency arises. Safety Issues of Immersion Suits The Board, concerned by the risks exposed to Canadian fishers in survival situations in hostile waters, has apprised TC of the following issues in a number of investigation reports: shortcomings in the maintenance of immersion suits13 lack of donning drill requirements14 insufficient training and education15 expediting the regulatory process regarding immersion suit carriage requirement16 should be unpacked and inspected periodically; should be refolded at different locations before re-storing to minimize stresses on welded/glued seams and reduce material failures that could result in leaks; zippers must be maintained and lubricated at regular intervals; repairs must be done by the manufacturer, an agent authorized by the manufacturer, or any other manufacturer who can demonstrate a proficiency acceptable to TC; and should be maintained onboard as per manufacturer's instructions. should be unpacked and inspected periodically; should be refolded at different locations before re-storing to minimize stresses on welded/glued seams and reduce material failures that could result in leaks; zippers must be maintained and lubricated at regular intervals; repairs must be done by the manufacturer, an agent authorized by the manufacturer, or any other manufacturer who can demonstrate a proficiency acceptable to TC; and should be maintained onboard as per manufacturer's instructions. The IMO17 has established guidelines for periodic testing of immersion suits; however, such testing is not required in Canada. Under the SFVIR, TC does not require small fishing vessels (some 19500vessels across Canada) to carry immersion suits, placing those aboard at risk. However, the Workers' Compensation Board of British Columbia (WCBBC) requires a good-quality, properly fitting suit to be on board for each crew member. In the proposed Fishing Vessel Safety Regulations, TC intends to require fishing vessels under 24m to carry immersion suits for each member of the complement. Vessels on voyages nearer to shore may carry anti-exposure suits in lieu of immersion suits.18 Both the CGSB standard and the WCBBC require that an individual should be able to unpack and properly don the immersion suit unassisted within two minutes.